WINNER - Cwmtawe Cluster - Cwmtawe Pathway Service: Providing Person-Centred Care for Patients with Complex Needs

Swansea Bay University Health Board

Swansea and Neath Port Talbot cluster mapping data from 2017/2018 recorded domestic violence (DV) incidents within 1,000m of each GP practice. This demonstrated that across the Swansea Bay University Health Board (SBUHB), DV was an issue to be tackled. Within Cwmtawe alone there were 18,215 female patients aged 15+ with 902 incidents of DV recorded by police and one domestic homicide.

A meeting with the Domestic Abuse Hub, Cluster and Health Board representatives took place. Stakeholders felt that a post addressing the ‘Key 3’ issues (Domestic Violence, Substance Misuse and Mental Health) was essential. It was also felt that a worker based within primary care would enable robust partnership working between sectors. Swansea Council for Voluntary Service advised they could support the service and ensure that patients had improved knowledge of local provision with their involvement. The Cwmtawe Pathway Service was approved to begin in July 2021 to address the issues faced by individuals. It also provides systemic support to family members as needed.

The service provides ‘person-centred care’, allowing time, space and flexibility to co-produce meaningful interventions that tackle the multiple unmet needs and/or issues faced. Some of the aims of the service are to: reduce demand on GPs, provide better support for patients to take responsibility for their own health, improve access to other sources of support and identify ‘hidden causes’ of poor physical and mental health issues.

83 referrals were received over the initial 18-month period, and the pilot effectively demonstrated a 60% reduction in demand on GPs following intervention. 98% of the patients seen are now taking responsibility for their own health, and 98% of patients seen have accessed other vital sources of support. Following intervention, ‘hidden causes’ of poor physical and mental health were identified in 100% of patients.